Ver. 12/13/07
New York State Department of Health
M/WBE Procurement Forms
The following forms are required to maintain maximum
participation in M/WBE procurement and contracting:
1.
Bidders Proposed M/WBE Utilization Form
2.
Minority Owned Business Enterprise Information
3.
Women Owned Business Enterprise Information
4.
M/WBE Utilization Plan
5
M/WBE Letter of Intent to Participate
6.
M/WBE Staffing Plan
3/08
New York State Department of Health
BIDDERS PROPOSED M/WBE UTILIZATION PLAN
Bidder Name:
RFP Number
RFP Title:
Description of Plan to Meet M/WBE Goals
PROJECTED M/WBE USAGE
%
Amount
100
$
1.
Total Dollar Value of Proposal Bid
2.
MBE Goal Applied to the Contract
$
3.
WBE Goal Applied to the Contract
$
4.
M/WBE Combined Totals
$
3/08
New York State Department of Health
MINORITY OWNED BUSINESS ENTERPRISE (MBE)
INFORMATION
In order to achieve the MBE Goals, bidder expects to subcontract with New York State certified MINORITYOWNED entities as follows:
MBE Firm
(Exactly as Registered)
Name
Projected MBE
Dollar Amount
Description of Work (Products/Services) [MBE]
$
Address
City, State, ZIP
Employer I.D.
Telephone Number
(
)
Name
$
Address
City, State, ZIP
Employer I.D.
Telephone Number
(
)
Name
$
Address
City, State, ZIP
Employer I.D.
Telephone Number
(
)
3/08
New York State Department of Health
WOMEN OWNED BUSINESS ENTERPRISE (WBE)
INFORMATION
In order to achieve the WBE Goals, bidder expects to subcontract with New York State certified WOMENOWNED entities as follows:
WBE Firm
(Exactly as Registered)
Projected WBE
Dollar Amount
Description of Work (Products/Services) [WBE]
Name
$
Address
City, State, ZIP
Employer I.D.
Telephone Number
(
)
Name
$
Address
City, State, ZIP
Employer I.D.
Telephone Number
(
)
Name
$
Address
City, State, ZIP
Employer I.D.
Telephone Number
(
)
3/08
New York State Department of Health
M/WBE UTILIZATION PLAN
Agency Contract:______________________________________
Telephone:______________________
Contract Number:______________________________________
Value:____________________
Date Bid:________________ Date Let:__________________
Date:___________________
Dollar
Completion
Contract Awardee/Recipient:___________________________________
Name
_____________________________________________________________
Address
_____________________________________________________________
Telephone
Description of Contract/Project
Location:___________________________________________________
Subcontractors Purchase with Majority Vendors:
Participation Goals Anticipated:________________ % MBE __________________% WBE
Participation Goals Achieved:
________________ % MBE __________________% WBE
Subcontractors/Suppliers:
Firm Name
and City
Description
of
Work
Dollar
Value
Identify if
MBE or WBE
or
NYS
Certified
Date of
Subcontract
Contractor’s Agreement: My firm proposes to use the MBEs listed on this
form
Prepared By:
(Signature of Contractor)
Print Contractor’s Name:
Telephone #:
Date:
Grant Recipient Affirmative Action Officer Signature (If applicable):
FOR OFFICE USE ONLY
Date:
Reviewed: By:
M/WBE Firms Certified:_______________
Certified:_____________________
CBO:_______________
Not
MCBO:_____________________
3/08
New York State Department of Health
MWBE ONLY
MWBE SUBCONTRACTORS AND SUPPLIERS
LETTER OF INTENT TO PARTICIPATE
To: ________________________________
Federal ID Number: ___________________
(Name of Contractor)
Proposal/ Contract Number: _______________________
Contract Scope of Work: ______________________________________________________
The undersigned intends to perform services or provide material, supplies or equipment
as:_________________________________
______________________________________________________________________________
Name of MWBE:
______________________________________________________________
Address:
_____________________________________________________________________
Federal ID Number:
____________________________________________________________
Telephone Number:
____________________________________________________________
Designation:
MBE - Subcontractor
Joint venture with:
WBE - Subcontractor
Name: ____________________________
Address: _________________________
MBE - Supplier
________________________________
WBE - Supplier
Fed ID Number: ___________________
MBE
WBE
Are you New York State Certified MWBE?
_____________Yes
3/08
_____________No
The undersigned is prepared to perform the following work or services or
supply the following materials, supplies or equipment in connection with the
above proposal/contract.
(Specify in detail the particular items of work or
services to be performed or the materials to be supplied): ___________________
______________________________________________________________________________
at the following price: $ _____________________________
The contractor proposes, and the undersigned agrees to, the following
beginning and completion dates for such work.
Date Proposal/ Contract to be started: _______________________________________
Date Proposal/ Contract to be Completed: _____________________________________
Date Supplies ordered: __________________________
Delivery Date: __________
The above work will not further subcontracted without the express written
permission of the contractor and notification of the Office.
The undersigned
will enter into a formal agreement for the above work with the contractor ONLY
upon the Contractor’s execution of a contract with the Office.
____________________
Date
______________________________________
Signature of M/WBE Contractor
______________________________________
Printed/Typed Name of M/WBE Contractor
INSTRUCTIONS FOR M/WBE SUBCONTRACTORS AND SUPPLIERS LETTER OF
INTENT TO PARTICIPATE
This form is to be submitted with bid attached to the Subcontractor’s
Information Form in a sealed envelope for each certified Minority or WomenOwned Business enterprise the Bidder/Awardee/Contractor proposes to utilize as
subcontractors, service providers or suppliers.
If the MBE or WBE proposed for portion of this proposal/contract is part
of a joint or other temporarily-formed business entity of independent business
entities, the name and address of the joint venture or temporarily-formed
business should be indicated.
Page 2
3/08
New York State Department of Health
M/WBE STAFFING PLAN
Check applicable categories:
Consultants


Project Staff

Subcontractors
Contractor
Name_________________________________________________________________________
Address
_________________________________________________________________
_________________________________________________________________
Total
Male
Female
Black
STAFF
Administrators
Managers/Supervisors
Professionals
Technicians
Clerical
Craft/Maintenance
Operatives
Laborers
Public
Assistance
Recipients
TOTAL
____________________________________________
(Name and Title)
____________________________________________
Date
3/08
Hispani
c
Asian/
Pacific
Islande
r
Other